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Based on facility document review and staff interview, the facility failed to develop and implement a policy and procedure that meet regulatory guidelines for the notification of individuals that transport patients to the Emergency Room of exposure to select infectious diseases.

Findings:

Review of the policy and procedure IPC 03-03, approved 12/08/2010, titled "Reporting of EMS and Other pre-hospital Personnel Exposures" did not include the requirement to notify individuals who transport patients to the hospital of exposure to a confirmed infectious disease diagnosis verbally that is followed-up by written notification within 48 hours.

Interview with the Infection Control Nurse on 08/16/2011 at 11:00 AM revealed that the written facility policy for notification did not specify how the notification would occur, but she stated that the employee's supervisor would be notified.

Based on observation and staff interview, the facility failed to ensure that all medications are stored securely.

Findings:

Observation, on 08/16/2011 at 2:10 PM in the Post Anesthesia Care Unit, revealed 20-25 10 ml prefilled 0.9% Sodium Chloride syringes stored in a unlocked cabinet drawer located across from the 3 recovery beds.

Interview with the Post Anesthesia Care Unit nurse on 08/16/2011 at 2:10 PM revealed that the room is cleaned by the housekeeping staff in the evening and is not supervised by any Post Anesthesia Care Unit staff.